Sorin M.

Dudea MD, PhD

R A D IO LO G Y A N D IM A G IN G
IN M ED IC A L & S U R G IC A L
EM ER G EN C Y

G eneralcourse content
Techniques, rationale
Head & neck
Spine, musculoskeletal, peripheral

vessels
Chest & heart
Digestive system
Urinary tract, retroperitoneum, pelvis
Integrative algorithms

G eneralinform ation
Course masters:
Assoc. Prof. Anca Ciurea
Prof. Sorin Dudea

Layout: lectures
Date / time:
every Wednesday
6,00 8,00 p.m.
Physiology auditorium
Start: Feb. 26th end: Apr. 9th (7 weeks)

G eneralinform ation
Final assessment:
written test, last lecture (no test no mark!)

Presence:
mandatory, Radiology style

Prerequisites: none
Dress / behavior code:
Smart casual or formal / academic

References
Sutton D Textbook of Radiology and

Imaging 7th Ed Churchill

Livingstone, Elsevier, Edinburgh,
2003
Brooke Jeffery R et al Diagnostic

Imaging, Emergency Amirsys, Salt

Lake City, 2007

Q uestions?

Course 1.

TEC H N IQ U ES

U S ED FO R EM ER G EN C Y

IM A G IN G

R ATIO N A LE
EM ER G EN C Y PATIEN T

TO A P P R O A C H TH E

Teaching O bjectives
Review the techniques used for

imaging:
Advantages
Drawbacks
Pifalls

Rationale to approach the patient

In an emergency setting
By means of imaging

Em ergency
Trauma
Non-trauma
Surgical
Medical

W here does im aging fi

t in?
Traum a or N on-traum a

TRAUMA
ATLS
Adjuncts to primary
survey & resuscitation
AP - CXR, AP pelvis,
C-spine
US FAST

Adjuncts to secondary
survey
Add. XR,
CT
others

NON TRAUMA
Based on
Clinical presentation
Guidelines / protocols

Im aging techniques
Radiography + fluoroscopy
Ultrasound
CT
MR
Interventional
Nuclear Medicine & PET-CT

Radiography & fl
uoroscopy
PLUS
Quick
Very good for chest & skeleton (fractures)
Low - dose, cost
Easy - recognizable anatomy,
interpretation
Guidance (fluoro)

Marincek et al Emergency Radiology,

2007

Radiography & fl
uoroscopy
Minus
Limited value in the abdomen & soft
tissues
No solid fluid differentiation
No information on the brain status
Ionizing radiation

Pitfalls
Superposition
Missed lesions

Radiography & fl
uoroscopy
WHEN?
TRAUMA, SOME SURGICAL

EMERGENCIES
adjunct to primary survey in ATLS
Adjunct to secondary survey in ATLS

WHAT?
Bone
Air

U ltrasonography
PLUS
No radiation
Quick, bedside, portable
Low cost
Ease of use
Very good solid fluid differentiation
Good abdomen & soft tissue assessment
No-contrast flow assessment
May be performed on hemodyn. unstable
pts.
Real-time guidance

U ltrasonography
MINUS
Operator dependant
Impossible behind gas & bone
Very difficult in obese pts.
Limited FOV & penetration

Pitfalls
Due to improper adjustment & poor
technique

U ltrasonography
WHEN?
TRAUMA, MEDICAL & SURGICAL

EMERGENCIES
adjunct to primary survey in ATLS
Adjunct to secondary survey in ATLS

WHAT?
Fluid
Status of solid organs
Flow

Com puter Tom ography (CT)

PLUS
Large volume acquisition in short time
Multiplanar reconstruction
Excellent soft tissue + bone + airways resolution
Quick
Wide FOV
Easy understood & reproducible
Very sensitive to bleeding (extravascular blood)
Excellent for stones & fractures
CM when needed
Guidance

Marincek et al Emergency Radiology,

2007

CT
MINUS
High radiation dose
Beware pregnancy & children !

More difficult access

Only for hemodyn. stable patients
Higher cost
Nonspecific

Pitfalls
Poor technique

CT
WHEN & WHAT
in the hemodynamically stable patient
EVERYTHING !!

The gold tool for emergency imaging

M agnetic Resonance Im aging

(M R)
Plus
Good soft tissue resolution, including spine
Numerous sequences
CM

MR
Minus
Difficult access
No ferromagnetic metal allowed
No life support
Long + expensive
Claustrophobia

Pitfalls
Technical + artifacts

MR -

is N O T an em ergency tool

WHEN?
Vertebromedullary trauma with suspicion
of cord lesion
Peculiar cases, special indications
Eg. Stroke + pregnancy

What?
Peculiar, focused aspects (eg. Cord
homogeneity & integrity)

N uclear M edicine + PET-CT

Not used in emergency

Interventionalradiology
Applications
Treat conditions diagnosed by the other
techniques
NOT diagnostic in emergency but
THERAPEUTIC

Rationale
for approaching the emergency patient

1.The requested investigation

should be useful
What is a useful investigation ?
Result (+ or -) will influence the clinical
course of the patient
Diagnosis (establish / confidence)
Treatment / Management

Q uestions to be asked (and answ ered)

BEFO RE requesting an exam
(iRefer RCR,London,2012)

1. Has is been done already ?

2. Do I need it?
3. Do I need it now?
4. Is this the best investigation?
5. Have I explained the problem?

H as it been done already?

Recent exams that may explain
Obtain history, previous reports &

images
Avoid repeating unnecessarily
Especially exams using XRay

D o Ineed it?
Dont request exams
just to be covered
When results are unlikely to change the
management
to do this exam as well overinvestigation
When the anticipated positive finding is:
irrelevant
Unlikely

To be reassured (although you already have

the diagnosis)

D o Ineed it now ?
Too early, before
Known onset of morphologic changes
There is any chance of progression /
resolution
The result may influence management

Always consider appropriate timing

Is this the best investigation?

D o Ineed this ?
Best is the one

that is:
Quick
Accurate
Available
Least irradiating
Easy to perform
Inexpensive

Is this the best investigation?

D o Ineed this ?
Best is the one

Best is not the one

that is:

that is:

Quick
Accurate

Most sophisticated
Highest in demand

Available
Least irradiating

Fanciest
Most expensive

Easy to perform
Inexpensive

Requiring the

greatest skill for

operation

Is this the best investigation?

D o Ineed this ?
Best is the one

Best is not the one

that is:

that is:

Quick
Accurate

Most sophisticated
Highest in demand

Available
Least irradiating

Fanciest
Most expensive

Easy to perform
Inexpensive

Requiring the

greatest skill for

operation

Usefulness should always be checked against the suspected

diagnosis and the clinical problem addressed.

H ave Iexplained the problem ?

Provide to the radiologist:
Appropriate clinical information
Questions that imaging should answer

Ask for a clinically relevant answer (dont

tell the radiologist what and, especially,

how to do)
OR FACE:
Wrong technique
Wrong focus of the report

2.The requested investigation should

be perform ed at the proper tim e
Too early (see above)
Too late (result will no longer

influence management)

3.The investigations should be

perform ed in the proper sequence
Whenever possible, comply with

guidelines, protocols or strategies.

If not certain, discuss with the
radiologist.

4.Risk /benefi
t should alw ays favor
the patient
Use the less irradiating technique

(ALARA) that provides appropriate

information
Dont hesitate to use irradiating

techniques if mandatory.

Irradiation
(iRefer,RCR,London,2012)

Examination
Limbs / joints

Eq. no.
chest XR

Eq. period of natural

Bg. irrad.

<1

<2 days

2,5 days

Lumbar spine

40

3 months

Mammography (2
view)

35

3 months

Abdomen

30

2 months

140

11,5 months

90

7,5 months

CT chest /
abdomen+pelvis

450

3 years

CT chest + abdomen
+ pelvis

670

4,5 years

1200

8,1 years

Chest (single PA)

IVP
CT head

PET-CT body (F-18

Irradiation & CT

Mettler FA & al Radiology, 253, 2009

Irradiation & CT

Mettler FA & al Radiology, 253, 2009

Clinicalquizzes
A GP requests a

chest x-ray for a

63-year-old woman
who has recently
joined his practice.
She is
asymptomatic

A Guide to Justification for Clinical Radiologists RCR, 2000

Clinicalquizzes
A GP requests a

chest x-ray for a

63-year-old woman
who has recently
joined his practice.
She is
asymptomatic

The practitioner (a

clinical radiologist)
determines that
the clinical details
do not justify the
exposure and
returns the request
to the GP with an
A Guide to Justification for Clinical Radiologistsexplanatory
RCR, 2000
letter.

Clinicalquizzes
A 24-year-old

woman presents
with right iliac
fossa pain. The
pregnancy test is
negative, and the
referrer (the
Accident &
Emergency
specialist) requests
abdominal CT for

A Guide to Justification for Clinical Radiologists RCR, 2000

 The clinical

Clinicalquizzes
A 24-year-old

radiologist (the
practitioner)
recommends
ultrasound
(including
transvaginal and
graded
compression
studies) as an
effective
alternative
technique which
does not involve
ionising radiation.

woman presents
with right iliac
fossa pain. The
pregnancy test is
negative, and the
referrer (the
Accident &
Emergency
specialist) requests
abdominal
CT
forRadiologists RCR, 2000
A Guide
to Justification for
Clinical

Clinicalquizzes
A 35-year-old

woman presents
with a breast lump.
The surgeon
requests a
mammogram.

A Guide to Justification for Clinical Radiologists RCR, 2000

Clinicalquizzes
A 35-year-old

The radiographer

(operator) does not

authorise the mammogram
as it falls outwith
departmental guidelines.
The clinical radiologist
(practitioner) determines
that the risk to benefit ratio
in a patient of this age
would not justify an
exposure and an
ultrasound is performed
which confirms features of
A Guide to Justification for Clinical Radiologists
RCR, 2000
a benign
fibroadenoma.

woman presents
with a breast lump.
The surgeon
requests a
mammogram.

Thank you !